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FRACTURES OF THE UPPER END OF THE RADIUS IN THE ADULT.

BY MM. LATARJET AND GAZET.

(Translated for The Railway Surgeon.)

By "upper end" we mean that portion of the bone down to and including the tuberosity. The etiology of these fractures is very simple, frequent in children-possibly on account of the late junction with the shaft, which does not take place before 20 to 25 years of age— they are rare in adults. Males, naturally, on account of their more laborious occupations, are more subject to them.

The pathogeny is very much more interesting. They are divided into direct and indirect fractures. The former may be produced (1) by violence perpendicular to the axis of the radius; (2) by violence parallel to the axis (fractures by impaction). Indirect fractures by Indirect fractures by (1) torsion, or (2) by muscular action. Direct fractures, we believe, are more frequent in the adult. Direct fractures. (a) By violence perpendicular to the axis. According to authors, these are due to violent. trauma acting on the upper end of the bone, impact of the arm itself against an angular object, gunshot, etc. Our attempts to produce this variety in the cadaver by direct violence were unsuccessful.

(b) By violence parallel to the axis (fracture by impaction). In this variety the patient falls on the palm of the hand, the arm extended and slightly abducted. This mechanism often produces fractures of the lower end, and sometimes impacted fractures of the upper end. In these cases the beveled upper end of the shaft penetrates the radial head, which, being held by the condyle of the humerus, gives way.

Indirect fractures. By torsion, Brossard's experiments on the cadaver have furnished the experimental proof of these fractures, which are most common in the young. Pronation causes a true helicoidal fracture, the apex of the V-shaped line of fission sometimes reaching to the upper end. As a rule, however, they are limited to the shaft.

By muscular action. This variety may be found in the adult as well as in children. In some exceptional cases where the whole weight of the body is thrown suddenly on the flexed forearm the violent contraction of the biceps may tear its bony insertion loose, together with the upper epiphysis. They can not occur very frequently, owing to the resistance of the radius, and the infrequency of the conditions under which it may probable take place.

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perpendicular to the axis, the fragments being separated variable degree, depending on the amount of

The latter also determines the angle at which the fragments are displaced. Generally the sine is posterior, and exaggerated by the contraction of the biceps. In violent degrees of trauma, a sprain of the elbow may exist with more or less dislocation of the radial head, generally forward. Lesions of the joint may ensue, though these are rare.

(3) Shattering of the head. The lesions in this variety are considerable, and the prognosis far from good. An oblique line of fracture generally separates the shaft from the upper epiphysis. The violence continuing, the lower end of the detached epiphysis is penetrated by the shaft and shattered. This shattering generally takes place in a vertical direction, producing two fragments, the anterior being the larger. The latter may be again fissured.

The

These hitherto undescribed fractures are grave. shattering is not the only lesion and gives rise to other disorders. The orbicular ligament is lacerated; the integrity of the upper radio-ulnar articulation is compromised. The lacerated external lateral ligament causes the twist. Lastly, the joint capsule is torn. Such fractures are true intra-articular ones, hemarthrosis is constant and the joint movements seriously impeded. If left alone the fragments, when uniting, give rise to bony formations in the joint, producing absolute impotence of it.

4. By muscular action. The X-ray shows an oblique line of separation from behind forward at the tip of the tuberosity. Along the tendon of the biceps may be seen bony particles torn off by the tendon itself. The joint is intact.

SYMPTOMS AND DIAGNOSIS.

Two clinical facts are evident. Sometimes the diagnosis is difficult; sometimes, on the contrary, the fracture is easily recognized. When the fragments are not displaced and the bone keeps its normal form and direction there are few objective signs. If there is displacement, on the contrary, we may make an exact diagnosis, even without the X-ray. Hence we must study fractures without and with displacement.

I. Fractures without displacement. The first sign is pain, which is most marked at a variable distance from the interarticular line. It must be sought for in front, externally and on the posterior surface of the forearm. Strong pressure on the forearm, grasping it at the lower part, sometimes causes pain at the exact point of fracture. It may also be evidenced by forced movements of the elbow, especially pronation. Contraction of the muscles, limiting these movements, aids a little in locating the fractured point. Flexion is generally less limited and painful. Extension is limited by the contraction of the biceps, the tendon is painful on pressure and lateral movement. Exploration of the elbow shows its integrity. Slight ecchymosis is seen over the antero-external part of the elbow, and the upper part of the forearm. The patient. usually carries his arm slightly flexed and semi-pronated. Measurements show nothing. To these, of course, must be added radiography.

2. Fractures with displacement. The patient's attitude is somewhat characteristic; the forearm forms an obtuse

angle with the arm, intermediate between a right angle and complete extension. Holding his forearm with the hand of the sound side, he complains of violent pain over the upper part of the forearm. This region is swollen, doughy; palpation causes acute pain an inch or so below the condyle of the humerus. By comparing the two forearms a slight swelling is sometimes perceptible over the antero-external aspect of the affected side.

The radial head is often difficult to distinguish, either on account of the swelling or because of slight forward subluxation. When it is perceptible, pronation and supination should be carried out. In some cases this confirms the diagnosis. When the fracture is due to direct violence there is no impaction, hence the head of the bone does not move when the forearm is rotated. The location of pain in these movements denotes the site of the fracture. Crepitus may be elicited, but as a rule it is either wanting or but slightly marked. Moreover, it is difficult to distinguish from that met with in dislocations. of the head of the radius.

If the fragments are widely separated a depression will be found on the postero-external surface. On the other hand, on the anterior surface the epicondylar muscles are elevated, forming a marked prominence below the line of the joint. Flexion and extension are painful and always restricted. During flexion the biceps tendon is very prominent, and painful on pressure. Pronation and supination are very limited, and painful, especially the latter. The ecchymosis is located on the antero-external aspect and extends up to the crease of the elbow.

Finally, in impacted fractures certain joint phenomena are added, hemarthrosis may be present, with the ordinary symptoms of a sprain; the painful, swollen joint hides the fracture and complicates the diagnosis.

TREATMENT.

When confronted with a fracture at the upper end of the radius the surgeon should watch out for the effects on the elbow and the radio-ulnar joints. Immobilization in a plaster cast should not be practiced, save in some special cases, where there is marked displacement or the fragments cannot be kept in position. Even in these cases the cast should be removed as soon as possible, 10 or 15 days after the accident.

In most instances, when the surgeon is consulted soon, very moderate massage is indicated, at first once or twice daily. During the intervals the arm is kept in a sling, semi-pronated and at a right angle. After the pain and swelling have disappeared the seances of massage may be longer and passive motion commenced.

In cases of long standing, with ankylosis of the elbow, resection of the head of the radius is indicated, with removal of the osteophytes in the joint. After the operation the usual measures are indicated-immobilization in semi-pronation, massage, electricity, etc.-Lyon Medical.

If urine escapes from a wound of the penis or perineum during the act of micturition it shows that there is a wound of the urethra. The escape of urine from a wound independently of micturition will indicate

wound of the bladder.-Gould.

Never remove a true carcinoma of the breast without clearing out the axillary glands.-Fenwick.

Extracts and Abstracts.

GLYCO-THYMOLINE IN MINOR SURGERY.

The value of glyco-thymoline in minor surgery lies in its thorough cleansing qualities, and in its maintenance of aseptic conditions, healing by "first intention." This value is demonstrated also in the arresting of suppurative conditions, with rapid reduction of inflammation, again maintaining asepsis and favoring rapid resolution. The fact that glyco-thymoline is non-irritating, soothing, and tends to the rapid reduction of inflammation in the surrounding tissues, as well as the fact that it does not coagulate sero-albumen, are strong points favoring its use.

Another point of great value is in the preparation of aseptic and moist dressings. Absorbent gauze wet with pure glyco-thymoline not only gives the physician a perfectly aseptic dressing, but in addition it remains sufficiently moist at all times; these points combined with its antiseptic value make it an ideal dressing.

When speaking of surgical dressings, M. A. Brinkman, M. D., of New York, states: "Glyco-thymoline has condition, if any good absorbent gauze is soaked with no equal for any ordinary wound. Say in a fairly aseptic

it, then packed in or on the wound and bound there, healing by first intention is the invariable rule-the dressing dries but still remains antiseptic to a degree, and your glycerin base tends to keep the gauze soft and to a sufficient extent moist. When removing the dressing, if any particles adhere to the edges of the wound, I dissolve them off with peroxid. This dressing I have found to be entirely satisfactory from every standpoint."

"I

Z. B. Sawyer, M. D., Cleveland, O., states: have never tried glyco-thymoline in catarrhal troubles, but have the greatest respect for it as an antiseptic nonirritating solution in wounds. A short time ago a prominent instructor in one of our local colleges was riding on his wheel, when by accident he was thrown to the pavement, sustaining a bad cut over the eye. These accidents happening on the pavements are particularly dangerous, as all forms of germs are mingled with the dust of the roads. Strictest antisepsis and cleansing areimperative here, in order to avoid most disastrous results. Thoroughly cleansed with glyco-thymoline, put in four stitches and bandaged the wound. I let this gofor about six days, at the end of which the patient returned to my office to have the stitches removed. Not a trace of pus or sign of infection were present, the wound exhibiting a perfectly healthy condition."-Ex.

Report of B. & O. Relief Department.-The report of the relief department of the Baltimore & Ohio for the month of September gives the number of cases of accidental death as six, of accidental injury 1,089, of surgical expenses 1,138, natural sickness 862, natural death 21, involving an expenditure of $47,173.25, which is increased by general expenses, contributions refunded, advances for artificial limbs and advances for hospital bills, to $54,265.44. In the month of October the number of accidental deaths is placed at 17, accicental injury cases 1,098, surgical expense cases 1,071, natural sickness cases 871, natural deaths 31, making total benefits of $63,984.64, which amount is increased by general expenses, etc., to $71,388.59.

Notices and Reviews.

"Nose and Throat Work for the General Practitioner." By George S. Richards, M. D. Pp., 344, with 78 illustrations. New York City: The International Journal of Surgery 'Company. Cloth, $2.00.

This book is to be particularly recommended to the general practitioner who wishes to quickly acquire the salient points requisite in the diagnosis and treatment of cases falling under the classification indicated by the title. The descriptions given of both procedures and conditions are all concise and clear, so as to constitute an admirable guide for the beginner, and at the same time contain so many original and practical suggestions from the author's personal experience that even the specialist will find much therein to interest. One of the commendable and unique features of the book is the practical suggestions, from time to time given, as to the value in different conditions of galvno-faradic electricity. EDWIN PYNCHON.

"Surgery; Its Theory and Practice." By William Johnson Walsham. Eighth Edition, 622 illustrations, including 20 skiagram plates by Walter George Spencer. Philadelphia: P. Blakiston's Son & Co. 1903. Price, $4.50 net. The latest edition of Walsham's Surgery contains. 1,197 pages. The author, whose untimely death we have been called on lately to deplore, was assisted in its preparation of Mr. Spencer. Notwithstanding the limitations. of space, the authors have succeeded in presenting all the most important facts. In several instances, notably appendicitis, the views presented are more in accord with surgical thought in this country than is usually the case with works by English surgeons. The new illustrations are over 100 in number, and altogether the work is well suited for the practitioner, and especially the senior medical student.

"The Physician's Visiting List" (Lindsay and Blakiston's) for 1904. Fifty-third year.

This familiar acquaintance again appears in its sober garb, containing the usual blank pages for professional engagements, with a number of useful tables.

"The American Illustrated Medical Dictionary." For Practitioners and Students. A Complete Dictionary of the Terms Used in Medicine, Surgery, Dentistry, Pharmacy, Chemistry and the kindred branches. By W. A. Newman Dorland, A. M., M. D., editor of the "American Pocket Medical Dictionary." Large octavo, nearly 800 pages, bound in full flexible leather. Philadelphia, New York, London: W. B. Saunders & Co. Chicago: W. T. Keener & Co. 1903. Price, $4.50 net; with thumb index, $5 net.

We have had occasion before to point out the excellences of Dorland's Dictionary. We have yet to be disappointed in the search for a word in its pages. Several hundred new definitions have been added to the present edition, and the tables correspondingly enlarged. It is remarkable how large the one on eponyms is becoming, due to their increasing use in current medical literature, though vigorously decried by many authorities.

"The American Pocket Medical Dictionary." Edited by W. A.

Philadelphia, New York, London: W. B. Saunders & Co. Chicago: W. T. Keener & Co. 1903. Flexible leather, with gold edges, $1 net; with thumb index, $1.25 net. The "baby" Dorland has the good features of its parent, though, of course, on a smaller scale. It is truly multum in parvo.

"The Medical Record Visiting List, or Physicians' Diary." New Revised Edition. 1904.

This edition has been revised to increase the amount of matter calculated to be useful in emergencies, and eliminate such as might better be referred to in the physician's library. The most important change is in the list of remedies and their maximum doses, in both

apothecaries' and decimal systems, and indicate such as are official in the United States Pharmacopoeia. "Clinical Examination of the Urine and Urinary Diagnosis." A Clinical Guide for the Use of Practitioners and Students of Medicine and Surgery. By J. Bergen Ogden, M. D., formerly Instructor in Chemistry, Harvard University Medical School., etc. Second Revised Edition. Octavo, 418 pages, illustrated, including II plates, nine in colors. Philadelphia, New York, London: W. B. Saunders & Co. Chicago: W. T. Keener & Co. 1903. Cloth, $3 net.

In this edition special effort has evidently been directed toward making the text complete and bringing it down to the present day. Important changes have been made in Part I, especially in connection with the determination of urea, uric acid and total nitrogen, and the subjects of cryoscopy and beta-oxybutyric acid have been given a place. The changes in Part II, while not so extensive, are nevertheless numerous and practical, and show that the author has spared neither pains nor time in making the revision thorough. It is a good book, and to be recommended to both student and practitioner, who will

find it a valuable aid.

"A Text-Book of Pathology." By Alfred Stengel, M. D., Professor of Clinical Medicine in the University of Pennsylvania. Octavo, 933 pages, with 394 text illustrations, many in colors, and seven full-page colored plates. Philadelphia, New York, London: V. B. Saunders & Co. Chicago: W. T. Keener & Co. 1903. Cloth, $5 net; sheep or half morocco, $6 net.

As before stated in these columns, this work considers. the bearing of pathology on clinical medicine very fully, hence it is especially adapted for the physician's use.

In the revision the first half of the book, on general processes, has been most changed, and special attention has been given immunity, including Ehrlich's side-chain theory, etc. The special pathology has not been overlocked, though requiring less extensive revision. A new feature is a chapter on technic, including all the standard methods. This treatise strikes us as being one of the most satisfactory smaller pathologies in any language.

PAMPHLETS RECEIVED.

"Fracture of the Spine: Three Cases-Primary Retroperitoneal Sarcoma," by Howard J. Williams, A. M., M. D., of Macon, Ga.

"Treatment of Acute Appendicitis by the Ochsner Method-General Surgical Anesthesia," by Ernest J

Mellish of El Paso, Tex.

"An Old-Time Quack Eve Doctor-Bacteria in the Newman Dorland, M. D. Containing the pronounciation Eye-Cytotoxins and Sympathetic Ophthalmia-Retinal Rosette Formations of Neuroglia in Inflammatory Processes," by Brown Pusey, M. D., of Chicago.

and definition of the principal words used in medicine and kindred sciences, with 566 pages and 64 extensive tables.

VOL. X.

A Nonthly Journal of Traumatic Surgery

"FIRST AID."*

CHICAGO, FEBRUARY, 1904.

BY E. N. ALLEN, M. D., SOUTH M'ALESTER, I. T.

I crave your indulgence for presenting for your consideration and discussion a subject that is, apparently, "threadbare," but one I consider of paramount importance to the success of railway surgery. The results in every

No. 9

occur in the hand or foot, it means the loss of tendons, fingers or toes, and even loss of foot or hand and possibly life. I recall one poor fellow who suffered a severe contused and lacerated wound of the dorsal surface of the second and third phalanges of the right ring finger. This was dressed by a local physician with carbolized oil and absorbent cotton, and the injured man told to return to his work. After about ten days he was sent to the hos

lowing the tendons to the carpo-metacarpal junction, necessitating amputation at the metacarpo-phalangeal ar

ticulation, with removal of the tendons above the point of suppuration. Now, if the attending surgeon had made the field of injury in this case thoroughly sterile, trimmed away the contused tissue and dressed the finger with a sterile dressing, there would have been no necessity of the man losing his finger.

railway injury depend upon the attention the injured pital with the finger suppurating badly, and the pus folparties receive at the time the injury is sustained-it matters not whether the injury be a minor or major one. The present knowledge of antiseptic and aseptic methods in surgery make it absolutely inexcusable for a surgeon to dress a recent injury, or a long-standing one for that matter, with carbolized oil. Such dressings, however, find their way to our hospitals occasionally. Thorough asepsis in your "First Aid" not only hastens the recovery of the injured, but lessens the danger of the injury becoming permanent. In addition to this it impresses the injured of your painstaking care and leads them to believe that the company employs none but skilled surgeons to look after them, and in this way renders it much easier for the company, in making settlements with them (provided, however, there is any responsibility on the part of the company).

I regret very much to be compelled to say that we have a few local surgeons-and only a few-on the line of the Choctaw, Oklahoma & Gulf Railroad, who feel that when they have applied a temporary dressing, of plain, unsterilized cotton and sent the patient to the hospital, they have fulfilled their duty to the injured and the company. Of course, when you are called to a wreck, where there are a number injured, you would not be expected to render the field of injury, in every case-or probably in any case-sterile, but you can at least in every case cover the field of injury with a sterilized dressing until the injured could be hastily moved to the nearest hospital, or some place where you could render the field of injury sterile, before completing your dressing. I recall one instance on the line of our road where the local surgeon not only sutured an extensive lacerated and contused wound at the place of wreck, without any effort to clean up the wound, but left a large sliver of wood in the wound, which was not discovered until the patient had been in the hospital for several days, and the wound had begun to suppurate.

You can all readily understand how impossible it is to expect union by first intention after such work. This class of work all suppurates, of course, and means not only delays in recovery, but sometimes when the injuries

Read at the drst annual meeting Rock Island Surgical Association, Kansas City, Dec. 3-4, 1903.

Every surgeon, at a minimum expense, can prepare himself to do thoroughly aseptic work at his office, both in minor and major injuries.

For the past fourteen years I have had a one-burner gasoline stove in my office, which I have used in conjunction with a small Arnold sterilizer, to sterilize both instruments and dressings. Of course, I have dispensed with the Arnold sterilizer, for the reason that I have had the good fortune for the past six years to have a hospital in town, and now I absolutely refuse to do major operations either in my office or private houses.

In addition I have three or four small brushes, made from vegetable material. Regardless of how minor an injury is, when a patient comes into my office I heat water, sterilize my hands, and make the field of injury sterile, then proceed to dress the patient with the same care that I would exercise in the amputation of a limb. This can easily be done in the case of all minor injuries, for the injured are almost invariably sent to your office in such cases.

In case you are called to see an injured person with crushed arm or leg, suffering from shock, loss of blood or both, you will at once stay the bleeding, probably by pressure, until you can have the injured moved to your office or some dwelling, where you can operate on him. You will find it necessary, in all probability, to give him. a 4 or 1⁄2 grain of morphia hypodermatically, for the purpose of quieting the patient's fears, and to assist in reaction. If there is either great loss of blood or great shock, I would at once give my patient a normal saline solution, preparing the arm, of course, for the operation. in the same way that you would if you were going to do an amputation.

It is not necessary to have a regular transfusion appar

atus for the purpose; a fountain syringe and hypodermic needle, a small glass pipette or a small canula you use in aspirating, is all that is needed.

One teaspoonful of chlorid of sodium to the pint of sterilized water at a temperature of 110 to 120 degrees F. is the temperature I prefer.

The more profound the shock the higher I prefer the temperature of the salt solution. I am ashamed to tell you just how hot I have used the solution, with excellent results, for fear you might think me exaggerating.

I prefer the median basilic vein for transfusion, but will pick up any vein that seems sufficiently large to receive the needle or pipette. Any surgeon who has a reasonable knowledge of anatomy can do this.

I desire to state here that I do not approve of the solutions being used by hypodermoclysis, for I believe its use in this way adds to the shock instead of relieving it. If I could not use it intravenously I believe I would prefer it per rectum. In cases of "First Aid" in fractures and dislocations I never put the injured member in a fixed dressing and especially not if they are to be transported.

In these cases I would recommend a pasteboard splint, prepared most suitably from a suit box, trimmed and molded, so when well padded with cotton it fits the limb comfortably. Include the joint above and below the fracture or dislocation.

I would like to report a few cases, treated by me in the last six or seven years, illustrating the good results from thoroughly aseptic methods in "First Aid."

Case 1. J. W., coal miner, age 35. Employed by the Choctaw, Oklahoma & Gulf Railroad Company at the Alderson mines. In June, 1897, he sustained a compound dislocation of head of the left tibia and fibula. The dislocation, fortunately, was on the inner side of the leg and upward, not in any way interfering with the circulation or nerve supply.

The field of injury was made thoroughly aseptic (this) in a coal miner's cabin!), the reduction made, the fragments of lacerated tendons and muscles trimmed off, the wound closed with chromicized catgut, and after ten days put in fixed dressing. We, in the first place, advised amputation, which was refused. Our prognosis was unfavorable. We told him, of course, if we should fortunately save his leg it would be anchylosed at the knee and he would always have a stiff leg. Nothing that we told this man occurred. He went on to complete recovery, and has good use of his leg, there not being any cvidence of anchylosis after five months from injury.

Case 2. William McC-, age 30. On June 1, 1902, this man, with some others, had stolen a handcar, and was riding on the main line of the Choctaw, Oklahoma & Gulf Railroad, when the car was derailed, producing a compound, comminuted fracture of the right tibia and fibula in the upper part of the middle third. The leg was thoroughly ground in with grease and cinders. The field of injury was shaved and made thoroughly aseptic, opening in the leg enlarged and wound cleaned, the fragments of bone removed, and the bleeding checked. The ends of bone were brought together, the wound sutured with chromicized catgut, the parts dressed aseptically, and fixed dressing applied, extending at least 10 inches above the knee and involving the foot. The man went on to

an uneventful recovery, never developing a surgical temperature.

Case 3. H. D., age 22, coal miner. This was a compound, comminuted fracture of the right leg, and involved the middle third of the leg. He was brought to the hospital June 22 by private conveyance, a distance of 15 miles. The procedure in this case was the same as in the previous one, except the incision was made at least 10 inches in length, and the only pieces of bone removed were those completely divested of periosteum. This man's recovery was complete. He left on September 28.

Case 4. C. J., age 40, fireman on Missouri, Kansas & Texas Railroad. Compound, comminuted fracture of frontal bone over right eye, with fracture of both orbital plates, compound, comminuted fracture of right temporal bone, and compound, comminuted fracture of the right zygomatic arch. The frontal bone was driven into the longitudinal sinus, so much so that in removing the loose bone the blood spurted at a frightful rate.

This man had two of the most violent convulsions between the time of the injury, at 7 a. m., and the time I operated on him, about 9:30 a. m., it has ever been my misfortune to witness. This injury was the result of a head-on collision, occurring in the yards at South McAlester. I saw this man in less than thirty minutes after he sustained the injury, and had him in the hospital by 8 o'clock. The preparation of the patient, which was most thorough, and the operation, required about one hour and thirty minutes.

It was necessary to scrape the flap (extending from the ear almost to the nose and hanging down 3 or 4 inches) with a bone curette, until there was nothing left of the flap execpt the derma, in order, to render it surgically

clean.

I removed the entire zygomatic arch, the outer plate of the temporal bone, and portions of both orbital plates, and enlarged the opening in the frontal bone in order to stitch up the dura, covering longitudinal sinus. This man's recovery was complete and uneventful. Ten days later, when he left the hospital, the wounds had all healed by first intention.

Case 5. T. J. B., brakeman, age 23. He sustained a compound, comminuted fracture of the right ulna, within 2 inches of the elbow. This injury was caused by being caught between the drawhead and deadwood. The opening on the posterior surface of the arm exposed the olecranon process, while the anterior one exposed the elbowjoint.

This injury occurred at Sayre, I. T., 261 miles west of South McAlester, on July 28, about 2 p. m., and he was admitted to the hospital on July 29 about 10 p. m. Very fortunately the local surgeon had dressed the injury aseptically. The man was anesthetized, the field of injury again made aseptic, the wound enlarged, spicula of bone removed, and drainage tube inserted (on account of oozing) and left for forty-eight hours. He left the hospital on September 28, with a useful arm.

In conclusion, gentlemen, let me admonish you, if you are not able to render the field of injury aseptic, to at least dress the injury with antiseptic dressings before releasing them.

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